The purpose of this study was to determine how MCOs manage chronic pain. Potential approaches were examined in four main categories (which are not mutually exclusive):

  • implementation of guidelines
  • pharmacy management (including formulary composition)
  • care management
  • other approaches

Specific study questions included the following:

  • What proportion of MCOs have programs for management of chronic nonmalignant pain, and what are the key activities that are included in these programs, within each of the categories listed above?
  • How do MCOs identify their chronic pain populations?
  • To what extent are MCOs developing, disseminating, or endorsing guidelines for pain management?
  • Is the management of chronic pain seen as a relevant issue in the MCO’s quality-management and utilization-management programs?
  • What barriers have MCOs encountered in implementing their pain-management program activities?


Using a prospective mailed survey design, we examined the current state of pain-management activities within MCOs.

Study Population

The desired study population was composed of primary medical directors of all MCOs in the U.S. A mailing list of managed care medical directors, maintained by the Office of Health Policy and Clinical Outcomes and updated on a quarterly basis, was used to identify 100% of the population.

The preferred respondent was the senior medical director for each plan. When this individual could not be identified from the data file, a project team member placed a phone call to confirm the name and contact information for the most senior medical director in the organization. Individual health plans that are part of a larger organization (e.g., the individual Aetna, United Healthcare, and Cigna plans) were surveyed separately, because pain-management programs might not be established exclusively at the corporate level. The final sample was composed of 463 individuals who received the survey mailing. canadian pharmacy viagra

Data Collection

The project team developed a questionnaire, including mostly pre-coded questions. Room was left for respondents to write in comments or answers that were not on the pre-coded response lists. A panel of managed care personnel reviewed a draft of the questionnaire, and their feedback was collected through the syndicated SKILA online service. The revised questionnaire was then pilot-tested with a sample of five former managed care medical directors. On the basis of their input, a final questionnaire was formatted for mailing to the target sample.

The identified medical director of each MCO in the sample received a mailing consisting of the questionnaire and a response sheet. An introductory cover letter asked the medical director to forward the survey questionnaire to the person in the organization with the greatest responsibility for pain management if this person was someone other than the medical director. The cover letter noted that the respondent should be aware of the organization’s “big picture” approach to pain management (e.g., not necessarily the front-line pain-management nurse). The letter also explained that responses would be kept confidential and that all results would be presented in aggregate form only.

A $50 gift certificate was offered as an incentive for completing the questionnaire. Approximately eight weeks after the initial survey mailing, a second mailing was sent to those who did not respond to the initial mailing.

Data Management and Analysis

All responses were compiled in a Microsoft Access® (2000) database, which was established at the beginning of the study. The database contained all survey responses and participant information. SAS® (version 8.2) programming software was used to conduct data analysis. Descriptive statistics were calculated for all variables, and answers to open-ended questions were collated when appropriate. Variations in responses to particular questions for MCOs with different characteristics, such as books of business (commercial, Medicare, and/or Medicaid) or size, were investigated via cross-tabulation.